cardiology

What Older Adults Should Know About High Cholesterol

Coronary heart disease (CHD) is the leading cause of death in both men and women >65 years old, and it is also a major cause of long term disability. CHD is caused by cholesterol buildup in the blood vessels which supply blood to the heart. Several conditions, including high blood cholesterol, high blood pressure, diabetes, and cigarette smoking, increase the risk (or probability) that an individual will develop CHD. While the importance of measuring and treating high cholesterol levels in people <65 years old is well established, there is uncertainty about the best approach to treating high cholesterol in older adults. This paper outlines the position of the Society of Geriatric Cardiology on management of high cholesterol in persons 65 years old.

What is Cholesterol and How is it Measured?

Cholesterol is a fatty substance which circulates in the blood, and it is necessary for many important body functions. Cholesterol in the blood exists in several different forms, and each form can be measured with a simple blood test. The total cholesterol level is the sum of cholesterol levels in all of the different forms. A desirable total cholesterol level is less than 200 mg/dL. A level of 2009 is considered borderline elevated, and a level 240 is definitely elevated.

The most important forms of cholesterol with regard to CHD are the LDL cholesterol and HDL cholesterol. LDL cholesterol (sometimes referred to as "the bad cholesterol") is the form which most often leads to cholesterol buildup in the blood vessels of the heart and other organs. In general, a desirable LDL cholesterol level is <130 mg/dL. Levels of LDL cholesterol between 1309 are considered borderline elevated, and levels 160 are definitely elevated. As discussed below, in individuals with severe cholesterol buildup in the blood vessels and in those who have already developed CHD, it may be desirable to reduce the LDL cholesterol level to <100.

HDL cholesterol (often referred to as "the good cholesterol") actually helps remove cholesterol from the blood vessel walls. Elevated HDL cholesterol levels are considered "protective" against the development of CHD. Desirable HDL cholesterol levels are above 35 mg/dL in men and above 45 mg/dL in women. Women tend to have higher HDL cholesterol levels than men, and this contributes to the lower overall risk of CHD in women.

Who Should Be Treated?

Appropriate treatment of high cholesterol depends on several factors, including the levels of total cholesterol, LDL cholesterol, and HDL cholesterol; whether the individual has known CHD (e.g., a heart attack, angioplasty, or bypass operation); the presence of other CHD risk factors," such as high blood pressure, diabetes, or smoking; and the individual's age and overall health condition. For simplicity, individuals with high cholesterol levels can be divided into two major categories: those at high risk for a CHD event (e.g., heart attack) and those at relatively low risk.

The high risk category includes individuals with known CHD, as evidenced by a prior heart attack, angioplasty, bypass operation, or abnormal stress test, who have a total cholesterol level of 200 or greater or an LDL cholesterol of 130. This category also includes older individuals without prior CHD who have a total cholesterol 240 or an LDL cholesterol level 160 in combination with at least one other major risk factor, such as high blood pressure, diabetes, smoking, or an HDL cholesterol <35. Currently available evidence indicates that treatment of "high risk" individuals who are 65

years old is beneficial and reduces the likelihood of a heart attack or other CHD event. At the present time, treatment of high cholesterol in individuals >80 years old has not been adequately studied. However, most experts agree that it is reasonable to treat high risk individuals >80 years old who are otherwise healthy.

The low risk category includes individuals with known CHD whose total cholesterol and LDL cholesterol levels are already within the desirable range, and all patients without known CHD who are not otherwise at high risk as defined above. At the present time, there is not enough information to make firm recommendations about the treatment of high cholesterol in older, low risk individuals. Most experts agree, however, that dietary modifications, as described below, are appropriate in most cases, and that some individuals with very high total cholesterol or LDL cholesterol levels may benefit from medication.

How Should Cholesterol Be Treated?

Importance of diet. In all cases, treatment of high cholesterol requires adhering to a proper diet. This involves limiting the intake of fatty foods, particularly foods that are high in saturated fats and cholesterol. In general, reducing the intake of red meat, dairy products (except skim milk and low fat cheeses), eggs, baked goods (i.e., cookies, cakes, etc.), and fried foods is desirable. In addition, it is important to eat at least 5 servings of fresh fruits or vegetables daily, exercise regularly, avoid smoking, and control high blood pressure and diabetes if present.

Medication. There are now several different medications available which are effective in lowering total cholesterol and LDL cholesterol. Selection of a specific medication will therefore depend on individual circumstances. In almost all cases it is possible to lower cholesterol with minimal or no side effects. However, since side effects may occur with any medication, regular physician checkups are appropriate.

Goals of Treatment. In general, the goal of treatment is to bring cholesterol levels into the desirable range, i.e., a total cholesterol <200 and an LDL cholesterol <130. In some individuals who already have CHD, it may be desirable to reduce the LDL cholesterol even further, e.g., to <100 mg/dL. In most cases, another goal of treatment is to increase the level of HDL cholesterol ("the good cholesterol"). Regular exercise, weight reduction, not smoking, controlling diabetes, and certain medications can help raise the HDL cholesterol level.

Conclusions

Based on available information, it is the position of the Society of Geriatric Cardiology that:

All individuals >65 years old with known CHD or other CHD risk factors (high blood pressure, diabetes, smoking) should have a blood test to measure total cholesterol, LDL cholesterol and HDL cholesterol.

In "high risk" patients (as defined above) who are 65

years old, dietary modifications and, if necessary, cholesterol lowering medications are recommended to lower the total cholesterol and LDL cholesterol levels into the desirable range.

In "high risk" individuals >80 years old, and in all "low risk" individuals, dietary modification as a means for lowering cholesterol is appropriate; however, there is insufficient information regarding the effectiveness of medications in these situations, and treatment must therefore be left to the discretion of the patient's personal physician.